Provider Demographics
NPI:1790893824
Name:SHULKIN, MICHAEL C
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:C
Last Name:SHULKIN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1188 MONTGOMERY DR
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95405-4802
Mailing Address - Country:US
Mailing Address - Phone:707-542-3404
Mailing Address - Fax:707-542-3404
Practice Address - Street 1:1188 MONTGOMERY DR
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95405-4802
Practice Address - Country:US
Practice Address - Phone:707-542-3404
Practice Address - Fax:707-542-3404
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-28
Last Update Date:2010-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOPT7703TPA152W00000X, 152WC0802X, 152WP0200X, 152WS0006X, 152WV0400X, 152WX0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
No152WP0200XEye and Vision Services ProvidersOptometristPediatrics
No152WS0006XEye and Vision Services ProvidersOptometristSports Vision
No152WV0400XEye and Vision Services ProvidersOptometristVision Therapy
No152WX0102XEye and Vision Services ProvidersOptometristOccupational Vision
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0077030Medicaid
CAU05252Medicare UPIN
CASD0077030Medicaid